AMA meeting: Delegates say don't shortchange specialists to fund care model
■ The AMA will ask CMS to help practices become patient-centered medical homes and to support models that allow non-primary care doctors to qualify.
By Emily Berry — Posted June 29, 2009
Chicago -- In the discussion of how to pay for coordinated care under the patient-centered medical home model, the AMA House of Delegates agreed that primary care physicians should not be rewarded at the expense of specialists.
At its June Annual Meeting, the house voted to advocate that additional pay to physicians for operating a medical home should not come from a reduction to the pay of specialists. Delegates approved language that medical home payments not be subject to requirements for budget neutrality in Medicare, where an extra dollar spent somewhere means a dollar has to be cut elsewhere.
The house also approved recommendations that private plans and the Centers for Medicare & Medicaid Services develop one standard for a medical home, and that specialty practices as well as primary care practices should be able to serve as that home.
"Primary care needs more help. It just shouldn't come at the expense of specialists," said Kim Williams, MD, a cardiologist from Chicago and a delegate for the American College of Cardiology.
Spreading the benefit
Most of the delegates and others speaking in favor of adopting the language, which came from a Council on Medical Services report, were specialists. But primary care physicians who spoke offered no objections.
"It's the practice that's going to coordinate the care," said Dale Moquist, MD, a family physician from Sugar Land, Texas, and a delegate representing the American Academy of Family Physicians. "It's not specialty-specific."
The adopted recommendations call on the AMA to help create "incentives to design care coordination among providers who provide medical care for patients outside the medical home," which would spread the financial benefit of coordinated care among all of a particular patient's physicians.
The delegates' language also stated that the AMA should support the medical home model as a way to enhance care, but "without restricting access to specialty care."
"We do not believe that revenue should come out of specialists' pay," said Stephen Imbeau, MD, an allergist from Florence, S.C., and delegate from the South Carolina Medical Assn.
The recommendations delegates passed this year represent a continuation of a discussion that in 2008 resulted in the AMA's adoption of principles of the patient-centered medical home. Those principles originally were approved in 2007 by the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians and the American Osteopathic Assn.
The principles include a medical home infrastructure that allows physicians to have more continuous contact with patients, to coordinate care better across the entire health system and to use more evidence-based medicine in clinical decision-making. In turn, physicians should receive additional payments that reflect the added value the medical home has for patients.
Funding medical homes a concern
Delegates were concerned with how CMS would pay for the care coordination provided by a medical home.
Citing already low pay rates from Medicare for physicians across specialties, delegates agreed that the AMA should push for CMS to exempt any patient-centered medical home payments from the Medicare budget neutrality requirement. The house called on CMS instead to rely on savings from better care coordination to fund incentive pay for medical homes.
"It's clear the savings of having a medical home and coordination of care will save Part A and other parts of Medicare, so there's plenty of money to pay for additional care," said James Bull, MD, a family physician from Silvis, Ill., and an alternate delegate from the Illinois State Medical Society.
Delegates also called on the Association to push CMS to help physicians pay for the up-front cost of becoming a medical home.
As many concerns as physicians have about how the medical home model will be used, some, such as Donna Woodson, MD, a family physician from Toledo, Ohio, and a delegate for the Ohio State Medical Assn., felt the time had passed for more study.
Dr. Woodson called for setting aside one resolution that asked the AMA to investigate further the implications of the medical home model, allowing the delegates to "move forward with this concept and not wait for another study." Delegates adopted the amended recommendations of the Council on Medical Service in lieu of the resolution requesting further study.
In his address to delegates at the Annual Meeting, President Obama didn't endorse the medical home concept explicitly, but he did talk about some elements of the model in outlining his vision for health system reform.
"We need to bundle payments so you aren't paid for every single treatment you offer a patient with a chronic condition like diabetes, but instead paid well for how you treat the overall disease," he said. "We need to create incentives for physicians to team up, because we know that when that happens, it results in a healthier patient. We need to give doctors bonuses for good health outcomes, so we're not promoting just more treatment, but better care."